Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Friendship Health and Rehab Center Inc
Employer identification number
23-7126857
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here........................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2011.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
175
29
204
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
24,240,517
26,182,504
27,324,604
28,733,876
30,002,027
136,483,528
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
24,240,692
26,182,504
27,324,633
28,733,876
30,002,027
136,483,732
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
15,236,507
20,435,921
35,672,428
c
Add lines 7a and 7b..
15,236,507
20,435,921
35,672,428
8
Public support (Subtract line 7c from line 6.)
100,811,304
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
24,240,692
26,182,504
27,324,633
28,733,876
30,002,027
136,483,732
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
253,533
270,405
315,866
307,902
335,443
1,483,149
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
253,533
270,405
315,866
307,902
335,443
1,483,149
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
0
13
Total support. (Add lines 9, 10c, 11, and 12.)..
24,494,225
26,452,909
27,640,499
29,041,778
30,337,470
137,966,881
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
73.070 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
60.480 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
1.080 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
1.120 %
19a
33 1/3% support tests—2012.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2011.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
In previous periods the organization evaluated excess payments based on each governmental agency as a whole. For FYE 6/30/11, however, in accordance with Revenue Ruling 83-153, 1983-2 CB 48, IRC Sec(s) 170, the payments from individual patients rather than the governmental agencies were deemed to be the payors of Medicare or Medicaid payments for purposes of the one-third support test. Consequently, Medicare and Medicaid receipts for services provided to each patient were included as gross receipts to the extent of the greater of $5,000 or 1% of the organization's total support for the taxable year.
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
12000229
Software Version:
2012v2.0
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Friendship Health and Rehab Center Inc
Employer identification number
23-7126857
Identifier
Return Reference
Explanation
Form 990, Part V, Statements, Ln 2a & 2b
Friendship Health and Rehab Center, Inc. is the paymaster for itself and related companies. The corporation performs all payroll functions including payroll checks, W-2s, W-3s, form 941, paying payroll taxes, paying withholding taxes, and all necessary related reports. Each corporation has its own employees as follows:Friendship Health and Rehab Center, Inc. 644Friendship Apartment Village Corp. 20Eastwood Assisted Living, Inc. 61Professional Health Care Services, Inc. 44Friendship Pharmacy, Inc. 29Valley Management Co., Inc. 43LTC Services, Inc. 19Friendship Outpatient & Wellness Services, Inc. 14Friendship Foundation 2Total 876
990 Part VII
The organization shares board members and officers with related organizations. The average hours a week that each individual spends with each organization is as follows:Friendship Apartment Village Corp.: Edgar Baker .11 Glenn Combs .07 Edwin Feinour .71 Lucian Grove, Jr. .13 Suzanne Ranson .04 Joseph Vipperman .18 John Williamson, III .18 Calvin Lilly .08 Monty Plymale .13 Richard Sayers .36 Bobbie Sandel .16 Bob Lawson .13 Garnett Smith .13 Kathryn Oelschlager .27 Cynda Johnson .04Friendship Foundation: Edgar Baker .03 Glenn Combs .02 Edwin Feinour .22 Lucian Grove, Jr. .04 Suzanne Ranson .01 Joseph Vipperman .06 John Williamson, III .06 Calvin Lilly .02 Monty Plymale .04 Robert Sandel .05 Robert Lawson .04 Garnett Smith .04 Richard Sayers .11 Kathryn Oelschlager .08 Cynda Johnson .01 Charles M. Shannon 40.00 Russell Barksdale 40.00Valley Management Co., Inc.: Edgar Baker .71 Glenn Combs .42 Edwin Feinour 4.52 Lucian Grove, Jr. .85 Suzanne Ranson .28 Joseph Vipperman 1.13 John Williamson, III 1.13 Calvin Lilly .49 Monty Plymale .85 Robert Sandel .99 Robert Lawson .85 Garnett Smith .85 Richard Sayers 2.26 Kathryn Oelschlager 1.70 Cynda Johnson .28 Barbara Johnson 40.00Eastwood Assisted Living, Inc.: Edgar Baker .16 Glenn Combs .09 Edwin Feinour 1.00 Lucian Grove, Jr. .19 Suzanne Ranson .06 Joseph Vipperman .25 John Williamson, III .25 Calvin Lilly .11 Monty Plymale .19 Robert Sandel .22 Robert Lawson .19 Garnett Smith .19 Richard Sayers .50 Kathryn Oelschlager .37 Cynda Johnson .06Friendship Outpatient & Wellness Services, Inc. Calvin Lilly .03 Monty Plymale .05 Edwin R. Feinour .28 Edgar K. Baker .04 Glen Combs .03 John B. Williamson, III .07 Lucian Grove, Jr. .05 Suzanne Ranson .02 Joe Vipperman .07 Robert Lawson .05 Robert Sandel .06 Garnett Smith .05 Richard R. Sayers .14 Kathryn Oelschlager .11 Cynda Johnson .02
990 Part IV line 12b
The corporation participates in a consolidated audit with affiliated companies reported on Schedule R. When finished, the audited statements are presented to the Finance Committee and the board of directors by the external auditors.
Form 990, Part XI, Line 9
Other Changes In Net Assets Or Fund Balances - Other Decreases
Extraordinary Loss - Debt forgiven = -$2688827
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
Upon request, the company will provide copies of governing documents, policies, financial statements, and form 990's to persons asking for the documents.
Form 990, Part VI, Line 15b
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
The Compensation Committee of the Board routinely engages an external consultant to review benchmark compensation data for the CEO and other key management positions. A number of nationally recognized salary surveys are utilized as part of this process and the consultant's written report is received by the Committee and the full board. Annually, the Committee reviews the compensation for each member of this group utilizing the benchmark data and any adjustments in compensation are recommended from the Compensation Committee to the full board for consideration and approval.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
The policy is included in both the Employee Handbook and the Code of Conduct, which is issued to and discussed with each employee and board member. An annual letter affirming the policy and asking for written declarations of any potential conflicts is sent to all board members and approximately 20% of employees (all managers, business office staff, purchasing department staff, human resources staff, etc.). Responses are reviewed by the Corporate Compliance Officer, reported to the board, and acted upon as needed. Also, the corporation is aware of the business affiliations of officers and directors and ensures that each is aware of the affiliations. Whenever discussions occur in which a conflict exists, the individual recuses him/herself from the proceedings so the other members can discuss the matter freely. Each year a report is made to the board of directors describing the business affiliations and any business transactions that occurred during the year between the corporation and the external businesses in which the directors or officers are involved.
Form 990, Part VI, Line 11b
Form 990, Part VI, Line 11b: Form 990 Review Process
The business office prepares the Form 990 and forwards it to the CFO and CEO for review. The CFO and CEO return the Form 990 to the business office to resolve questions and make changes. The Form 990 goes back to the CFO and CEO to ensure questions and changes have been made. A copy of the Form 990 is then provided to each board member by the CFO approximately 2 weeks prior to the due date. They are given 1 week to review and forward questions to the CFO. Review questions are resolved and the Form 990 is filed.
Form 990, Part VI, Line 6
Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder
The corporation has one member, Friendship Foundation.
Form 990, Part VI, Line 3
Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company
The corporation pays management fees to Friendship Foundation and Valley Management Co., Inc. to provide management of all aspects of the operation, including, but not limited to human resource services, accounting, billing, collections, payroll, and general administration. Valley Management is responsible for coordinating the preparation of monthly financial statements, maintaining and managing bank accounts and working capital. Friendship Foundation and Valley Management are also responsible for applying for, obtaining, and maintaining all necessary licenses, permits, consents, and approvals from all governmental agencies wnich have jurisdiction over the operation of the organization. The two companies agree to operate and maintain the organization in compliance with the requirements of any statute, ordinance, law, rule, regulation or order of any governmental or regulatory body having jurisdiction over the organization.
Form 990, Part VI, Line 2
Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et
Lucian Grove, Jr., member of the board, is the brother-in-law of Richard Sayers, the corporate secretary.John Williamson, III and Edgar Baker, members of the board, are both on the board of directors of the Bank of Botetourt. Robert Lawson, member of the board,is on the Regional Advisory Board of SunTrust Bank. Friendship Foundation, a related company, has a $2,000,000 line of credit with the bank. At June 30,2013, the outstanding liability, was $0.Suzanne Ranson, member of the board, is the Executive Director of Good Samaritan Hospice. The corporation received $160,353 from Good Samaritan Hospice for patient care during the year ending June 30, 2013. Federal law requires Good Samaritan hospice to bill the room and board fee to Medicaid on behalf of its patients who are under hospice care while in a nursing facility. Therefore, the payments from Good Samaritan Hospice are to reimburse Friendship Health and Rehab Center for these room and board fees it has received from Medicaid.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.